Pediatric Coding Alert

Pediatricians are familiar with the coding dilemma of the child who presents for two services (such as a checkup and a sick visit) or a service and a procedure (such as a checkup and a wart removal) at the same encounter. Under certain circumstances, both can be billed by appending modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service.

As recently as a year ago, coders hesitated to use modifier -25, resulting in unnecessarily restricted revenues. But more payers are recognizing modifier -25 and even accepting it electronically. So do not be afraid to use it, as long as it is justified by the performance of a separately identifiable procedure or service. Although you can use modifier -25 only when a separate service is performed, this does not necessarily mean you need more than one diagnosis, according to CPT. But you must be able to document a separate service, which some coders recommend you provide by writing a separate paragraph, preferably on a separate page. Further, some payers ignore CPT rules and only pay on modifier -25 if there are two diagnoses, so when possible, use two diagnoses. Some procedures are starred, meaning the code does not include any pre- or post-treatment work. It also means that for you to bill an E/M service with a starred code, CPT requires you to append modifier -25 to the E/M service. Modifier -25 is necessary even when a procedure is not starred, says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer based in North Augusta, S.C. "You need modifier -25 because your payer probably has its system set up to look first for a modifier, whenever they see an E/M and a procedure, to explain why both codes are there," Callaway says. "It has less to do with whether the procedure is starred or not, and more to do with what the payer views as a minor surgical procedure. Most insurance companies lean toward Medicare's definition of a minor procedure, and not CPT's starred procedure terminology," she says, adding that next year the stars will be eliminated from CPT Codes . Preventive Medicine Service and Sick Visit A common modifier -25 scenario in pediatrics involves billing a sick visit in addition to a well visit. You can bill for both if significant extra work is done, according to CPT. In the introduction to the preventive medicine services codes (99381-99397), CPT states, "If an abnormality/ies is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem/abnormality [...]